Management of pediatric renal trauma: Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study

BACKGROUND

Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States.

METHODS

Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes.

RESULTS

In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%.

CONCLUSION

The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

A multicenter investigation examining timing of penile prosthesis infection management and responsible organisms

The purpose of this investigation was to examine the timing of penile prosthesis infection management by different responsible organisms. A retrospective cohort study was performed of patients who underwent penile prosthesis salvage or explant procedures due to a suspected infection between 2001 and 2018. The cohort consisted of 216 patients from 33 different facilities and six countries. The most common primary organisms responsible for device infections included, Gram-positives (31.5%), no growth cultures (30.6%), Gram-negatives (22.2%), fungal (11.6%), and anaerobic organisms (4.2%). Overall, median time to infection was 1.8 (interquartile range [IQR]: 1.0-3.0) months for all patients. Median time to infection management was similar between responsible organisms: 1.0 (IQR: 1.0-2.3) months for Gram-negatives and 2 months for Gram-positives (IQR: 1.0-1.4), fungal (IQR: 1.0-5.0), anaerobes (IQR: 1.0-2.5), and no growth cultures (IQR: 1.0-3.0, p = 0.56). Median time to infection management was significantly shorter among patients who received aminoglycoside/vancomycin prophylaxis (1.5 months, IQR: 1.0-2.5, p < 0.01) compared to other antibiotic groups. Median time to infection management was significantly longer for patients managed with a three-piece inflatable implant salvage procedure (2.8 months, IQR: 1.0-5.0, p = 0.02) compared to other salvage procedures. Conventional wisdom surrounding early versus late penile prosthesis infections should largely be abandoned. More than half of penile prosthesis infections are surgically managed within 2 months of initial device placement.

Prognostic significance of pT3a staging subclassifications in renal cell carcinoma: Not all pT3a are equal

OBJECTIVE

To examine the prognostic significance of perinephric fat, renal sinus fat, and renal vein invasion in patients with pT3a renal cell carcinoma (RCC) by histologic type.

METHODS

A population-based retrospective cohort study of patients with pT3aN0M0 RCC was performed using Surveillance, Epidemiology, and End Results (SEER) data for the years 2010 through 2019. Cox proportional hazards models were used to examine the relationship between pT3a subclassification groups and cancer-specific survival (CSS) by histological subtype (clear cell, papillary, chromophobe, and other).

RESULTS

The cohort consisted of 10,170 patients with pT3a RCC, including 8,446 (83.0%) with clear cell RCC and 1,724 (17.0%) with nonclear cell RCC (nccRCC). Median follow up was 36 months. Differences in CSS by pT3a subclassification groups were observed in all histological subtypes but were most pronounced in nccRCC, specifically papillary RCC. Compared to perinephric fat (PF) invasion only, renal vein (RV) invasion (HR = 4.9, 95%CI: 2.5-9.3, P < 0.01), renal sinus fat invasion (HR = 3.0, 95%CI: 1.4-6.2), RV and PF invasion (HR = 7.5, 95%CI: 3.5-16.0), and combination of all three characteristics (HR = 4.4, 95%CI: 1.2-15.5) were associated with worse CSS in patients with papillary RCC.

CONCLUSION

We examined the prognostic role of pT3a staging subclassifications in RCC by histologic subtype and observed survival differences, particularly in papillary RCC. Our findings highlight the need to refine pT3a staging criteria to help guide individualized, multimodal treatment strategies for locally advanced RCC.

Risk of Biochemical Recurrence in Patients With Grade Group 1 Prostate Cancer With Extraprostatic Extension Treated With Radical Prostatectomy

PURPOSE

We sought to examine the association of extraprostatic extension (EPE) with biochemical recurrence (BCR) separately in men with Grade Group (GG) 1 and GG2 prostate cancer (PCa) treated with radical prostatectomy.

MATERIALS AND METHODS

We reviewed our institutional database of patients who underwent radical prostatectomy for PCa between 2005 and 2022 and identified patients with GG1 and GG2 disease on final pathology. Fine-Gray competing risk models with an interaction between EPE (yes vs no) and GG (GG1 vs GG2) were used to examine the relationship between disease group and BCR-free survival.

RESULTS

The cohort consisted of 6309 men, of whom 169/2740 (6.2%) with GG1 disease had EPE while 1013/3569 (28.4%) with GG2 disease had EPE. Median follow-up was 4 years. BCR occurred in 400/6309 (6.3%) patients. For men with GG1, there was no statistically significant difference in BCR-free survival for men with vs without EPE (subdistribution HR = 0.88; 95% CI: 0.37-2.09). However, for GG2 patients BCR-free survival was significantly worse for those with vs without EPE (subdistribution HR = 1.97, 95% CI: 1.54-2.52).

CONCLUSIONS

Although there is a subset of GG1 PCas capable of invading through the prostatic capsule, patients with GG1 PCa and EPE at prostatectomy experience similar biochemical recurrence and survival outcomes compared to GG1 patients without EPE. However, among men with GG2, EPE connotes a worse prognosis.

Oncologic Outcomes in Patients with Residual Upper Tract Urothelial Carcinoma Following Neoadjuvant Chemotherapy

BACKGROUND AND OBJECTIVE

Growing evidence supports the use of neoadjuvant chemotherapy (NAC) for upper tract urothelial carcinoma (UTUC). However, the implications of residual UTUC at radical nephroureterectomy (RNU) after NAC are not well characterized. Our objective was to compare oncologic outcomes for pathologic risk-matched patients who underwent RNU for UTUC who either received NAC or were chemotherapy-naïve.

METHODS

We retrospectively identified 1993 patients (including 112 NAC recipients) who underwent RNU for nonmetastatic, high-grade UTUC between 1985 and 2022 in a large, international, multicenter cohort. We divided the cohort into low-risk and high-risk groups defined according to pathologic findings of muscle invasion and lymph node involvement at RNU. Recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) estimates were calculated using the Kaplan-Meier method. Multivariable analyses were performed to determine clinical and demographic factors associated with these outcomes.

KEY FINDINGS AND LIMITATIONS

Among patients with low-risk pathology at RNU, RFS, OS, and CSS were similar between the NAC and chemotherapy-naïve groups. Among patients with high-risk pathology at RNU, the NAC group had poorer RFS (hazard ratio [HR] 3.07, 95% confidence interval [CI] 2.10-4.48), OS (HR 2.06, 95% CI 1.33-3.20), and CSS (subdistribution HR 2.54, 95% CI 1.37-4.69) in comparison to the pathologic risk-matched, chemotherapy-naïve group. Limitations include the lack of centralized pathologic review.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Patients with residual invasive disease at RNU after NAC represent a uniquely high-risk population with respect to oncologic outcomes. There is a critical need to determine an optimal adjuvant approach for these patients.

PATIENT SUMMARY

We studied a large, international group of patients with cancer of the upper urinary tract who underwent surgery either with or without receiving chemotherapy beforehand. We identified a high-risk subgroup of patients with residual aggressive cancer after chemotherapy and surgery who should be prioritized for clinical trials and drug development.

Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial

BACKGROUND AND OBJECTIVE

The transrectal biopsy approach is traditionally used to detect prostate cancer. An alternative transperineal approach is historically performed under general anesthesia, but recent advances enable transperineal biopsy to be performed under local anesthesia. We sought to compare infectious complications of transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis.

METHODS

We assigned biopsy-naïve participants to undergo transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis (rectal culture screening for fluoroquinolone-resistant bacteria and antibiotic targeting to culture and sensitivity results) through a multicenter, randomized trial. The primary outcome was post-biopsy infection captured by a prospective medical review and patient report on a 7-d survey. The secondary outcomes included cancer detection, noninfectious complications, and a numerical rating scale (0-10) for biopsy-related pain and discomfort during and 7-d after biopsy.

KEY FINDINGS AND LIMITATIONS

A total of 658 participants were randomized, with zero transperineal versus four (1.4%) transrectal biopsy infections (difference -1.4%; 95% confidence interval [CI] -3.2%, 0.3%; p = 0.059). The rates of other complications were very low and similar. Importantly, detection of clinically significant cancer was similar (53% transperineal vs 50% transrectal, adjusted difference 2.0%; 95% CI -6.0, 10). Participants in the transperineal arm experienced worse periprocedural pain (0.6 adjusted difference [0-10 scale], 95% CI 0.2, 0.9), but the effect was small and resolved by 7-d.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Office-based transperineal biopsy is tolerable, does not compromise cancer detection, and did not result in infectious complications. Transrectal biopsy with targeted prophylaxis achieved similar infection rates, but requires rectal cultures and careful attention to antibiotic selection and administration. Consideration of these factors and antibiotic stewardship should guide clinical decision-making.

PATIENT SUMMARY

In this multicenter randomized trial, we compare prostate biopsy infectious complications for the transperineal versus transrectal approach. The absence of infectious complications with transperineal biopsy without the use of preventative antibiotics is noteworthy, but not significantly different from transrectal biopsy with targeted antibiotic prophylaxis.

Likelihood of sampling prostate cancer at systematic biopsy as a function of gland volume and number of cores

BACKGROUND

Pre-biopsy multiparametric magnetic resonance imaging (mpMRI) of the prostate is used to conduct targeted prostate biopsy (TB), guided by ultrasound and registered (fused) to the MRI. Systematic biopsy (SB) continues to be used together with TB or in mpMRI-negative patients. There is insufficient evidence on how to use SB to inform clinical decision-making in the mpMRI era. The purpose of this study was to estimate the effect of prostate volume and number of SB cores on sampling clinically significant prostate cancer (csPCa) using a simulation method based on clinical data.

METHODS

SBs were simulated using data from 42 patients enrolled in a transrectal ultrasound robot-assisted biopsy trial. Linear mixed models were used to examine the relationship between the number of SB cores and prostate volume on 1) clinically significant cancer detection probability (csCDP) and 2) percent of mpMRI depicted regions of interest (ROIs) sampled with the SB.

RESULTS

Median values and interquartile range (IQR) were 47.16 cm3 (35.61-65.57) for prostate volume, 0.57 cm3 (0.39-0.83) for ROI volume, and 4.0 (2-4) for PI-RADS v2.1 scores on MRI. csCDP increased with the increasing number of simulated SB cores and decreased substantially with larger prostate volume. Similarly, the percent of ROIs sampled increased with the increasing number of simulated SB cores and was lower for prostate volumes ≥60 cm3 compared to glands <60 cm3.

CONCLUSIONS

The effect of the number of SBs performed on detecting csPCa varies largely with gland volume. The common 12-core SB can achieve adequate cancer detection and sampling of ROIs in smaller glands, but not in larger glands. In addition to TB or in mpMRI-negative patients, the number of SB cores can be adjusted to prostate volume. Performing 12-core SB alone in ≥60 cm3 glands results in inadequate sampling and potential PCa underdiagnosis.

Effect of Transperineal Versus Transrectal Prostate Biopsy on the Quality of Hydrogel Spacer Placement in Men Prior to Radiation Therapy for Prostate Cancer

OBJECTIVE

To determine whether prostate biopsy type affects spacer placement quality using a large sample of patients treated in the ambulatory setting.

METHODS

A retrospective cohort study was conducted on patients diagnosed with prostate cancer who underwent hydrogel spacer placement before primary radiation treatment between 2018 and 2023 after transperineal (TP) or transrectal (TR) prostate biopsy. Study outcomes were Spacer Quality Score (SQS) (0-2, with greater values indicating better placement), Rectal Wall Infiltration (RWI) (0-3, with lower values indicating lack of RWI), and the occurrence of other hydrogel complications.

RESULTS

A total of 395 patients were included. A pre-hydrogel TR biopsy was performed in 273 patients (69.1%), while TP biopsy was performed in 122 (30.9%). A SQS ≥1 occurred in 308 (77.9%) patients. A greater proportion of TP patients had a favorable SQS (≥1) compared to those who underwent TR (87.7 vs 73.5%, P <.002). An RWI score ≥2 was found in 180 (45.6%) patients. The proportion of patients with an unfavorable RWI score (≥2) did not differ significantly by type of biopsy performed. Patients who had an interval of >70 days between biopsy and hydrogel placement had significantly decreased odds of an RWI score ≥2 (odds ratio = 0.42, 95% confidence interval: 0.21-0.83). Only one infection was found after hydrogel placement.

CONCLUSION

The quality of hydrogel placement was significantly better in men who had undergone TP biopsy. Rectal wall infiltration was more common than previously reported but did not differ between TP and TR biopsies.

Socioeconomic determinants of racial disparities in survival outcomes among patients with renal cell carcinoma

PURPOSE

Racially driven outcomes in cancer are challenging to study. Studies evaluating the impact of race in renal cell carcinoma (RCC) outcomes are inconsistent and unable to disentangle socioeconomic disparities from inherent biological differences. We therefore seek to investigate socioeconomic determinants of racial disparities with respect to overall survival (OS) when comparing Black and White patients with RCC.

METHODS

We queried the National Cancer Database (NCDB) for patients diagnosed with RCC between 2004 and 2017 with complete clinicodemographic data. Patients were examined across various stages (all, cT1aN0M0, and cM1) and subtypes (all, clear cell, or papillary). We performed Cox proportional hazards regression with adjustment for socioeconomic and disease factors.

RESULTS

There were 386,589 patients with RCC, of whom 46,507 (12.0%) were Black. Black patients were generally younger, had more comorbid conditions, less likely to be insured, in a lower income quartile, had lower rates of high school completion, were more likely to have papillary RCC histology, and more likely to be diagnosed at a lower stage of RCC than their white counterparts. By stage, Black patients demonstrated a 16% (any stage), 22.5% (small renal mass [SRM]), and 15% (metastatic) higher risk of mortality than White patients. Survival differences were also evident in histology-specific subanalyses. Socioeconomic factors played a larger role in predicting OS among patients with SRMs than in patients with metastasis.

CONCLUSIONS

Black patients with RCC demonstrate worse survival outcomes compared to White patients across all stages. Socioeconomic disparities between races play a significant role in influencing survival in RCC.

Ileal Conduit versus Continent Urinary Diversion in Radical Cystectomy: A Retrospective Cohort Study of 30-day Complications, Readmissions, and Mortality

OBJECTIVES

To quantify the short-term burden associated with continent diversion relative to ileal conduit creation.

METHODS

Bladder cancer patients who underwent radical cystectomy in 2019 and 2020 were identified in the American College of Surgeons National Surgical Improvement Program database using current procedural terminology codes and pathology reports. Patients were grouped by urinary diversion performed: ileal conduit versus continent diversion (neobladder or cutaneous reservoir). Multiple logistic regression was used to examine the association between type of urinary diversion and 30-day outcomes, including postoperative complications, all-cause readmissions, and mortality, adjusting for baseline differences.

RESULTS

Of 4,755 patients who underwent radical cystectomy, 677 underwent continent diversion (14.2%). These patients were significantly younger (median 62 vs. 71 years, p< 0.01) and less likely to have diabetes (13.6% vs. 20.1%, p<0.01), COPD (3.7% vs. 7.1%, p<0.01), and prior pelvic radiation (5.5% vs. 13.1%, p<0.01). A greater proportion of continent diversion patients experienced a postoperative complication (56.0% vs. 48.9%, p<0.01) and all-cause readmission (30.3% vs. 20.4%, p<0.0). After adjustment, continent diversion patients had 1.4 (95% CI: 1.1 - 1.7) and 1.7 (95% CI: 1.4 - 2.1) times the odds of experiencing a postoperative complication or all-cause readmission, respectively. There was no statistically significant difference in mortality (OR 1.2, 95% CI: 0.5 - 2.9).

CONCLUSIONS

Compared to ileal conduit creation, continent urinary diversion is associated with increased odds of postoperative complications and readmission to the hospital within 30 days of surgery. Bladder cancer patients undergoing cystectomy and seeking continent diversion should be counseled on the increased short-term morbidity associated with this specific type of diversion.

Current Findings Regarding Perioperative Complications in Benign Scrotal Surgery

OBJECTIVES

To characterize patients at the greatest risk of morbidity and mortality after benign scrotal surgery.

METHODS

A secondary data analysis was conducted of adults undergoing elective scrotal surgery for benign conditions using 2015-2020 American College of Surgeons National Surgical Quality Improvement data. Patients who experienced a postoperative complication, an unplanned procedure, or who died within 30-days of surgery were identified using the composite outcome "postoperative event". Multiple logistic regression was used to examine the association between patient characteristics and the odds of experiencing a postoperative event.

RESULTS

The study consisted of 12,917 patients, of which 4.1% experienced a postoperative event. After adjustment, malnourishment (OR 4.1, 95% CI: 1.2 - 14.5) decreased functional status (OR 3.8, 95% CI: 2.0 - 7.1), bleeding disorders (OR 3.4, 95% CI: 2.2 - 5.4), age ≥ 40 years (OR 1.6, 95% CI: 1.2 - 2.0), chronic obstructive pulmonary disease, (COPD, OR 1.8, 95% CI: 1.2 - 2.6), smoking (OR 1.4, 95% CI: 1.2 - 1.8), diabetes (OR 1.3, 95% CI: 1.1 - 1.7) and increased body mass index (BMI, OR 1.1, 95% CI: 1.1-1.1) were identified as risk factors for a postoperative event. The risk of a postoperative event was 2.7%, 4.5%, and 11.2% for patients with none, 1 to 2, and > 2 risk factors, respectively.

CONCLUSION

Complications after benign scrotal surgery are not infrequent. Risk factors include malnourishment, decreased functional status, bleeding disorders, age, COPD, smoking, diabetes, and increased BMI. Our results can be used to counsel patients on their risk of negative outcomes following these procedures.

Prophylactic parastomal mesh sublay at the time of ileal conduit: surgical technique

OBJECTIVE

To demonstrate the surgical technique for prophylactic mesh placement in the sublay position during ileal conduit creation because literature suggests that prophylactic mesh placement at the time of cystectomy may reduce the risk of parastomal hernias with low risk of mesh-related complications. Parastomal hernias are one of the most common complications following ileal conduit construction and occur in 17-65% of patients undergoing cystectomy with urinary diversion. Review of our institutions data demonstrated a high incidence of hernias associated with ileal conduits, which have substantial burden to patients, surgeons, and the healthcare system.

METHODS

This is a retrospective chart review of data from a single surgeon who performed cystectomy with ileal conduit for 12 patients with bladder cancer between 1/2021-3/2022 at our institution. These dates were chosen based on the timing of availability of literature suggesting a benefit from prophylactic mesh placement. Preliminary data was analyzed determine the incidence of parastomal hernia and mesh-related complications.

RESULTS

A total of 12 patients underwent cystectomy with ileal conduit between 1/2021-3/2022 at our institution. Eleven patients (92%) had prophylactic mesh placed during their procedure. Median follow up was 5.4 months (0.8-8 months). Two patients (17%) developed a parastomal hernia which was detected clinically and/or radiographically. The hernias occurred in patients with mesh and within 6 months of cystectomy. One patient had stomal stenosis eventually requiring surgical revision. There were no mesh infections or mesh removals.

CONCLUSIONS

Parastomal hernias are a common and morbid complication of ileal conduit urinary diversion. Our early experience demonstrates that the procedure is straightforward, adds little time to the surgical procedure, and is associated with a low complication rate. Our experience is too small and follow up too short to confirm that the results of the randomized trial can be matched at our center.

Partial Versus Complete Bacillus Calmette-Guérin Intravesical Therapy and Bladder Cancer Outcomes in High-risk Non-muscle-invasive Bladder Cancer: Is NIMBUS the Full Story?

Background

It is important to understand the implications of reduced bacillus Calmette-Guérin (BCG) treatment intensity, given global shortages and early termination of the NIMBUS trial.

Objective

To assess the association of partial versus complete BCG induction with outcomes.

Design, setting, and participants

This is a retrospective cohort study of veterans diagnosed with high-risk non–muscle-invasive bladder cancer (NMIBC; high grade [HG] Ta, T1, or carcinoma in situ) between 2005 and 2011 with follow-up through 2014.

Intervention

Patients were categorized into partial versus complete BCG induction (one to five vs five or more instillations). Partial BCG induction subgroups were defined for comparison with the NIMBUS trial.

Outcome measurements and statistical analysis

Propensity score–adjusted regression models were used to assess the association of partial BCG induction with risk of recurrence and bladder cancer death.

Results and limitations

Among 540 patients, 114 (21.1%) underwent partial BCG induction. Partial versus complete BCG induction was not significantly associated with the risk of recurrence in HG Ta (cumulative incidence [CIn] 46.6% vs 53.9% at 5 yr, p =  0.38) or T1 (CIn 47.1% vs 56.7 at 5 yr, p = 0.19) disease. Similarly, we found no increased risk of bladder cancer death (HG Ta: CIn 4.7%7vs 5.4% at 5 yr, p = 0.87; T1: CIn 10.0% vs 11.4% at 5 yr, p =  0.77). NIMBUS-like induction was associated with an increased risk of recurrence in patients with HG Ta disease, although not statistically significant. Unmeasured confounding is a limitation.

Conclusions

Cancer outcomes were similar among high-risk NMIBC patients who underwent partial versus complete BCG induction, suggesting that future research is needed to determine how to optimize BCG delivery for the greatest number of patients, especially during global shortages.

Patient summary

Outcomes were similar between patients receiving partial and complete courses of bacillus Calmette-Guérin (BCG) therapy. Future research is needed to determine how to best deliver BCG to the greatest number of patients, particularly during medication shortages.

Stent duration and increased pain in the hours after ureteral stent removal

INTRODUCTION To assess the relationship between pain after ureteral stent removal and patient and procedural factors.

MATERIALS AND METHODS

A validated survey designed to assess the relationship between quality of life and treatment decisions in kidney stone disease was randomly distributed to patients with a history of a ureteral stent in seven medical centers across North America participating in an endourology research collaborative between July 2016 and June 2018. The primary outcome was increased pain after ureteral stent removal. Statistical analyses were performed using Chi-square and multiple logistic regression.

RESULTS

A total of 327 surveys were analyzed. Twenty seven percent of patients reported increased pain in the hours after ureteral stent removal. Patients with a stent ≤ 7 days were significantly more likely to experience pain after stent removal compared to those with a stent > 7 days (33.3% versus 22.8%, p = 0.04). Female gender (OR: 2.41, 95% CI: 1.42-4.10) was associated with increased pain after stent removal, while increasing age was inversely associated (OR: 0.52, 95% CI: 0.36-0.74). After adjustment, patients with a stent > 7 days were significantly less likely to report pain in the hours after removal (OR: 0.59, 95% CI: 0.35-0.99).

CONCLUSIONS

Approximately one in four patients will experience increased pain after ureteral stent removal. Female patients, younger patients, and patients with a stent ≤ 7 days were more likely to experience an increase in pain immediately following stent removal. Understanding factors associated with post-stent removal pain may be helpful in counseling patients at high risk stent removal morbidity.

External validation of a nomogram predicting risk of bleeding control interventions after high-grade renal trauma: The Multi-institutional Genito-Urinary Trauma Study

BACKGROUND

Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers.

METHODS

We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI).

RESULTS

Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92).

CONCLUSION

Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level III.

Parastomal hernia development after cystectomy and ileal conduit for bladder cancer: results from the Dartmouth ileal conduit enhancement (DICE) project

INTRODUCTION Limited information exists regarding parastomal hernia development in bladder cancer patients. The purpose of this investigation was to describe the natural history of parastomal hernias and identify risk factors for hernia development in patients who undergo cystectomy with ileal conduit urinary diversion.

MATERIALS AND METHODS

A retrospective cohort study was performed of bladder cancer patients who underwent cystectomy with ileal conduit urinary diversion between January 1st 2009 and July 31st 2018 at Dartmouth-Hitchcock Medical Center. The primary outcome of interest was the presence of a parastomal hernia as evident on postoperative cross-sectional imaging obtained for disease surveillance.

RESULTS

A total of 107 patients were included with a mean age of 70.9 years and 29.9% being female. Parastomal hernias were identified in 68.2% of bladder cancer patients who underwent cystectomy with ileal conduit urinary diversion. Forty percent of patients with a parastomal hernia reported symptoms related to their hernia, while 12.5% underwent operative repair. After multivariate adjustment, patients with a postop body mass index (BMI) > 30 kg/m² (odds ratio [OR]: 21.8, 95% CI: 1.6-305.2) or stage III or IV bladder cancer (OR: 18, 95% CI: 2.1-157.5), had significantly greater odds of parastomal hernia development. Fifty percent of parastomal hernias were identified 1.3 years from surgery, while 75% were identified by 2 years after cystectomy.

CONCLUSION

Parastomal hernias developed in over two-thirds of bladder cancer patients and occurred rapidly following cystectomy and ileal conduit urinary diversion. Greater postoperative BMI and bladder cancer stage were identified as significant risk factors for parastomal hernia development. Significant opportunity exists to reduce morbidity associated with parastomal hernias in this population.

A rare case of a retroperitoneal lymphangioma causing chronic flank pain in an adult

Retroperitoneal lymphangiomas are exceedingly rare and typically asymptomatic. We present a case of a 27 year-old female with chronic right flank pain and cross-sectional imaging showing a large multi-cystic mass located medial and inferior to the right kidney. The patient underwent an uncomplicated robotic-assisted, laparoscopic resection of the mass with final pathology showing a benign lymphangioma. This case highlights the importance of recognizing retroperitoneal lymphangiomas as atypical causes of chronic flank pain and demonstrates that these benign tumors can be successfully resected robotically. Given today's urology residency training, urologists are likely uniquely positioned to best manage these peri-renal lymphatic malformations.

Understanding the relationship between health insurance and kidney stones: an examination of NHANES data

INTRODUCTION

To investigate the relationship between socioeconomic factors, specifically insurance status, and kidney stones using a nationally representative cohort.

MATERIALS AND METHODS

A retrospective secondary data analysis of National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2014 was performed. Using univariate statistics and multiple logistic regressions, we examined the relationship between socioeconomic factors and kidney stone history.

RESULTS

The weighted national prevalence of nephrolithiasis between ages 20 and 64 was 7.7% of a population of over 95.3 million. Fifty-three percent of the total population was female. The mean age was 42 years and the mean body mass index (BMI) was 28.7. The prevalence of nephrolithiasis was higher among individuals who had state-assisted insurance compared to those with private insurance (10.3% versus 7.3%, p = 0.005). On univariate regression analysis, having a college education was protective against stones compared to having less than a high-school degree (OR 0.62, 95% CI 0.43-0.84; p = 0.009). Income was also significantly associated with kidney stone prevalence. After adjusting for race, BMI, gender, water intake, income, and education level through multivariable analysis, having private insurance was associated with lower odds of developing nephrolithiasis compared to having state-assisted insurance (OR 0.62, 95% CI 0.44-0.89; p = 0.01).

CONCLUSIONS

Individuals with state-assisted insurance were found to have significantly increased odds of a kidney stone compared to those with private insurance. Urologists, primary care, and policy makers should recognize this disparity exists and target opportunities to elucidate mechanisms and provide intervention for this high-risk group.

Mischievous malakoplakia: A potential pitfall of mpMRI of the prostate?

Interpretation of multiparametric magnetic resonance imaging (mpMRI) for prostate cancer diagnosis and staging can be challenging and, in some cases, benign prostate disease can mimic locally advanced malignancy. We present the case of a 57 year-old male with biopsy-proven Gleason 3 + 4 prostate cancer and a preoperative mpMRI showing extraprostatic extension who was later found to have infiltrating malakoplakia on final surgical pathology. This case highlights the importance of recognizing that malakoplakia of the prostate can present as a PI-RADS 5 lesion with extracapsular extension on mpMRI. Such cases can result in wide-excision, non-nerve sparing radical prostatectomies that may be unwarranted.

The impact of low- versus high-intensity surveillance cystoscopy on surgical care and cancer outcomes in patients with high-risk non-muscle-invasive bladder cancer (NMIBC)

Purpose

To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC).

Materials & methods

A retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1–5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death.

Results

Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Risk of death from bladder cancer did not differ significantly by low (cumulative incidence [CIn] 8.4% [95% CI 6.5–10.9) at 5 years) vs. high-intensity surveillance (CIn 9.1% [95% CI 7.4–11.2) at 5 years, p = 0.61). Low vs. high-intensity surveillance was not associated with increased risk of bladder cancer death among patients with Ta (CIn 5.7% vs. 8.2% at 5 years p = 0.24) or T1 disease at diagnosis (CIn 10.2% vs. 9.1% at 5 years, p = 0.58). Among patients with Ta disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease (T1 or T2) or bladder cancer death (CIn 19.3% vs. 31.3% at 5 years, p = 0.002).

Conclusions

Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC.

A case of contralateral superficial inguinal recurrence of testicular embryonal carcinoma

Metastatic embyronal carcinoma to the subcutaneous tissues is rare. Prior cases have occurred in the setting of undiagnosed widely metastatic disease. Here we present the first case of metastatic embyronal cancer to the contralateral subcutaneous inguinal region in the absence of any other sites of metastatic disease.

'Dr Google': trends in online interest in prostate cancer screening, diagnosis and treatment

OBJECTIVES

To examine trends in online search behaviours related to prostate cancer on a national and regional scale using a dominant major search engine.

MATERIALS AND METHODS

Google Trends was queried using the terms 'prostate cancer', 'prostate-specific antigen' (PSA), and 'prostate biopsy' between January 2004 and January 2019. Search volume index (SVI), a measure of relative search volume on Google, was obtained for all terms and examined by region and time period: pre-US Preventive Services Task Force (USPSTF) Grade D draft recommendation on PSA screening; during the active Grade D recommendation; and after publication of the recent Grade C draft recommendation.

RESULTS

Online interest in PSA screening differed by time period (P < 0.01). The SVI for PSA screening was greater pre-Grade D draft recommendation (82.7) compared to during the recommendation (74.5), while the SVI for PSA screening was higher post-Grade C draft recommendation (90.4) compared to both prior time periods. Similar results were observed for prostate biopsy and prostate cancer searches. At the US state level, online interest in prostate cancer was highest in South Carolina (SVI 100) and lowest in Hawaii (SVI 64). For prostate cancer treatment options, online interest in cryotherapy, prostatectomy and prostate cancer surgery overall increased, while searches for active surveillance, external beam radiation, brachytherapy and high-intensity focused ultrasonography remained stable.

CONCLUSION

Online interest in prostate cancer has changed over time, particularly in accordance with USPSTF screening guidelines. Google Trends may be a useful tool in tracking public interest in prostate cancer screening, diagnosis, and treatment, especially as it relates to major shifts in practice guidelines.

Regional Variation in Shock Wave Lithotripsy Utilization Among Medicare Patients with Nephrolithiasis

OBJECTIVE

To characterize shock wave lithotripsy (SWL) utilization and assess for regional variation in the use of this procedure across the United States.

MATERIALS AND METHODS

We examined SWL and URS utilization among Medicare Beneficiaries with a diagnosis of nephrolithiasis for the years 2006, 2009, and 2014. Adjusted utilization rates were calculated per 1000 beneficiaries accounting for age, sex, and race. Utilization rates were examined nationally and by hospital referral region (HRR).

RESULTS

A total of 511,495, 604,493, and 806,652 Medicare beneficiaries had a diagnosis of nephrolithiasis in 2006, 2009, and 2014, respectively. The adjusted rate of SWL per 1000 beneficiaries with nephrolithiasis decreased from 59.4/1000 in 2006 to 52.2/1000 and 45.5/1000 in 2009 and 2014 (13.9% decrease, P < .001). Variation was observed in SWL utilization; up to a 12-fold difference between HRRs (9.2/1000 in Winchester, VA to 105.8/1000 in Lincoln, NE). The adjusted rate of URS per 1000 beneficiaries increased by 10.2% (P < .001) between 2006 and 2014. However, the percent decrease in SWL utilization did not correlate with the percent increase in URS utilization when examined by HRR (P = .66).

CONCLUSION

Variation exists in the utilization of SWL among Medicare beneficiaries (12-fold difference). This variation is likely secondary to a series of supply, urologist, and patient-specific factors. SWL utilization decreased between 2006 and 2014, while URS increased. Stone procedure type is likely highly dependent on where patients receive their urologic care.

Urothelial cell carcinoma of the bladder in pediatric patients: a systematic review and data analysis of the world literature

BACKGROUND

Urothelial cell carcinoma (UCC) of the bladder is exceedingly rare in pediatric patients. Limited data are available to guide management in this population.

METHODS

The authors systematically searched MEDLINE, Cochrane Library, and Google Scholar (through February 2019) for case reports and series to summarize data regarding presentation, evaluation, management, and follow-up for patients ≤ 18 years diagnosed with UCC of the bladder. Patient-level data were abstracted, and adjusted logistic regression was used to identify factors associated with a combined outcome of recurrence or death.

RESULTS

One hundred two articles describing 243 patients from 26 countries met criteria. Average age was 12.5 years, 32.6% were female, 15.3% had medical comorbidities, and 13.2% had known risk factors for bladder cancer. Initial management was transurethral resection in 95.5% of patients, whereas 6.2% required secondary intervention. Tumor stage was TaN0M0 in 86.4% and low grade in 93.4%. Recurrence and death occurred in 8.6% and 3.7%, respectively. Mean time to recurrence or death was 8.6 months (standard deviation [SD] 7.6) for 10.7%. Mean disease free follow-up without recurrence or death was 56.9 months (SD 54.2) for 89.3%. Patients with comorbidities, risk factors, or family history (odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.02-5.6); ≥TaN0M0 disease (OR: 6.2, 95% CI: 2.5-15.6); and larger tumors at diagnosis (OR: 1.7, 95% CI: 1.2-2.4) had significantly greater adjusted odds of recurrence or death after initial treatment.

CONCLUSION

Based on pooled results, disease recurrence or death occurred in 10.7% of pediatric patients and within 9 months for most and within 32 months for all patients. This may suggest that low-grade and stage UCC of the bladder in pediatric patients can be systematically monitored for at least 3 years. However, prospective evaluation of this clinical strategy is warranted.

A Review of Economic Evaluations of Erectile Dysfunction Therapies

INTRODUCTION

Erectile dysfunction (ED) is a common and costly urologic condition with increasing prevalence as men age. Cost-effectiveness of ED therapies and whether cost-effectiveness varies for different populations of men remains underexplored.

AIM

To review and summarize available published data on the economic evaluation of ED therapies and to identify gaps in the literature that still need to be addressed.

METHODS

All relevant peer-reviewed publications and conference abstracts were reviewed and incorporated.

RESULTS

There are a number of medical and surgical treatment options available for ED. The economic evaluation of phosphodiesterase-5 inhibitors, particularly sildenafil, has been well described. However, minimal research has been conducted to assess the cost-effectiveness of intracavernosal injections, intraurethral suppositories, penile prosthesis surgery, vacuum erection devices, and other emerging therapies in men with different causes of ED.

CONCLUSION

Available economic evaluations of ED therapies are dated, do not reflect present-day physician, pharmaceutical, and device costs, fail to account for patient comorbidities, and may not be generalizable to today's ED patients. Substantial research is needed to evaluate the cost-effectiveness of ED treatments across different patient populations, countries, and reimbursement systems. Rezaee ME, Ward CE, Brandes ER, et al. A Review of Economic Evaluations of Erectile Dysfunction Therapies. Sex Med Rev 2019;8:497-503.

Brief report: Impact of healthcare quality on prostate specific antigen screening for the early detection of prostate cancer

With recent guidelines emphasizing patient values, patient preferences and shared decision-making in regards to prostate specific antigen (PSA) screening it is important for primary care providers and urologists to identify factors that influence men's decisions to undergo PSA screening. We sought to evaluate the impact of men's perceptions of healthcare quality on obtaining a screening PSA for the early detection of prostate cancer. A retrospective secondary data analysis was conducted of men ages 55-69 without a history of prostate cancer using 2015 Medical Expenditure Panel Survey (MEPS) data. The relationship between Consumer Assessment of Healthcare Providers and Systems (CAHPS) questions captured in MEPS and PSA screening in the last two years were assessed using multiple logistic regression. The analysis was carried out in October 2018 at Dartmouth-Hitchcock Medical Center. The final survey sample consisted of 1249 men that equated to 15,313,605.5 once weighted; 69.5% underwent PSA screening. Men who were offered help with filling out forms in the office (OR: 1.86, 95% CI: 1.14-3.01) or rated the quality of healthcare from their doctors ≥7 (OR: 1.63, 95% CI: 1.10-2.44) on a scale from 0 (worst healthcare) to 10 (best health care) had significantly greater adjusted odds of undergoing PSA screening. Men who rated the quality of healthcare delivered to them as high had significantly greater odds of undergoing PSA screening compared to those who rated it lower. Our results may suggest that improvements in healthcare quality and patient experience of care have the potential to positively influence PSA screening.

sST2 as a novel biomarker for the prediction of in-hospital mortality after coronary artery bypass grafting

Objectives: Soluble suppression of tumorigenicity 2 (sST2) biomarker is an emerging predictor of adverse clinical outcomes, but its prognostic value for in-hospital mortality after coronary artery bypass grafting (CABG) is not well understood. This study measured the association between operative sST2 levels and in-hospital mortality after CABG. Methods: A prospective cohort of 1560 CABG patients were analyzed from the Northern New England Cardiovascular Disease Study Group Biomarker Study. The primary outcome was in-hospital mortality after CABG surgery (n = 32). Results: After risk adjustment, patients in the third tercile of pre-, post- and pre-to-postoperative sST2 values experienced significantly greater odds of in-hospital death compared to patients in the first tercile of sST2 values. The addition of both postoperative and pre-to-postoperative sST2 biomarker significantly improved ability to predict in-hospital mortality status following CABG surgery, compared to using the EuroSCORE II mortality model alone, (c-statistic: 0.83 [95% CI: 0.75, 0.92], p value 0.0213) and (c-statistic: 0.83 [95% CI: 0.75, 0.92], p value 0.0215), respectively. Conclusion: sST2 values are associated with in-hospital mortality after CABG surgery and postoperative and pre-to-post operative sST2 values improve prediction. Our findings suggest that sST2 can be used as a biomarker to identify adult patients at greatest risk of in-hospital death after CABG surgery.

Examining 30-day COPD readmissions through the emergency department

Background

Thirty-day readmission in COPD is common and costly, but potentially preventable. The emergency department (ED) may be a setting for COPD readmission reduction efforts.

Objective

To better understand COPD readmission through the ED, ascertain factors associated with 30-day readmission through the ED, and identify subgroups of patients with COPD for readmission reduction interventions.

Patients and methods

A retrospective cohort study was conducted from January 2009 to September 2015 in patients with COPD of age ≥18 years. Electronic health record data were abstracted for information available to admitting providers in the ED. The primary outcome was readmission through the ED within 30 days of discharge from an index admission for COPD. Logistic regression was used to examine the relationship between potential risk factors and 30-day readmission.

Results

The study involved 1,574 patients who presented to the ED within 30 days on an index admission for COPD. Of these, 82.2% were readmitted through the ED. Charlson score (odds ratio [OR]: 3.6; 95% CI: 2.9–4.4), a chief complaint of breathing difficulty (OR: 1.6; 95% CI: 1.1–2.6), outpatient utilization of albuterol (OR: 4.1; 95% CI: 2.6–6.4), fluticasone/salmeterol (OR: 2.3; 95% CI: 1.3–4.2), inhaled steroids (OR: 3.8; 95% CI: 1.3–10.7), and tiotropium (OR: 1.8; 95% CI: 1.0–3.2), as well as arterial blood gas (OR: 4.4; 95% CI: 1.3–15.1) and B-type natriuretic peptide (OR: 2.2; 95% CI: 1.4–3.5) testing in the ED were associated with readmission (c-statistic =0.936). Seventeen-point-eight percent of patients with COPD presented to the ED and were discharged home; 56% presented with a complaint other than breathing difficulty; and 16% of those readmitted for breathing difficulty had a length of stay <48 hours.

Conclusion

Intensive outpatient monitoring, evaluation, and follow-up after discharge are needed to help prevent re-presentation to the ED, as practically all patients with COPD who represent to the ED within 30 days are readmitted to the hospital and for a variety of clinical complaints. Among those patients with COPD who present with breathing difficulty, improved decision support algorithms and alternative management strategies are needed to identify and intervene on the subgroup of patients who require <48-hour length of stay.

Combined Post- and Precapillary Pulmonary Hypertension in Patients With Heart Failure

BACKGROUND

Pulmonary hypertension (PH) is a well-recognized complication of left ventricular heart failure (HF).

HYPOTHESIS

Differences exist in demographic, clinical, hemodynamic, and survival characteristics of patients with left ventricular HF who have combined postcapillary and precapillary PH (CpcPH), isolated postcapillary PH, or no PH.

METHODS

A secondary data analysis was conducted using a large prospective database of patients undergoing right heart catheterization from 1994 to 2012. One-year mortality postcatheterization was assessed between PH groups using Kaplan-Meier and log-rank techniques, as well as a multivariate Cox proportional hazards model adjusted for age, sex, diabetes, chronic kidney disease, atrial fibrillation, and chronic obstructive pulmonary disease. Mortality rates were calculated for each group as deaths per 100 person-years.

RESULTS

Of the 724 patients identified, 29.4% (n = 213) had no evidence of PH, 63.1% (n = 457) had isolated postcapillary PH, and 7.5% (n = 54) had CpcPH. Compared with no PH, there was an increased mortality rate within 1 year for CpcPH patients (crude hazard ratio: 5.22, 95% confidence interval: 2.06-13.22), but not for isolated postcapillary PH patients (crude hazard ratio: 2.12, 95% confidence interval: 0.99-4.57). Adjusted analyses revealed similar results. Mortality rates per 100 person-years were 3.9, 8.4, and 21.0 for no PH, isolated postcapillary PH, and CpcPH patients, respectively.

CONCLUSIONS

Heart failure patients with CpcPH are associated with increased death rate 1 year post-cardiac catheterization, compared with patients without PH. They are a high-risk PH group and should be evaluated and diagnosed earlier in the disease state.

Robot-Assisted Laparoscopic Nephroureterectomy for Transitional Cell Carcinoma of a Right Pelvic Kidney

BACKGROUND

Nephroureterectomy is the standard of care for transitional cell carcinoma (TCC) involving the upper urinary tract. However, few published case reports exist describing the surgical treatment of ectopic kidneys with TCC. Surgical removal of a pelvic kidney can be complicated by aberrant vasculature supply, a tortuous ureter and abutting anatomical structures. Thus, it is necessary to determine the most appropriate surgical technique for treatment of pelvic kidneys with suspected malignancy.

CASE PRESENTATION

A 65-year-old female who presented with hematuria and lower abdominal pain was found to have a right pelvic kidney with a heterogeneous mass on computed tomography (CT) urogram. A robot-assisted laparoscopic nephroureterectomy of the right pelvic kidney was performed. Histopathological analysis revealed high-grade TCC with microscopic extension through the muscularis propria of the renal pelvis and superficially into the renal parenchyma.

CONCLUSION

This case demonstrates the successful use of robot-assisted laparoscopic nephroureterectomy in the treatment of a pelvic kidney with TCC. Preoperative CT angiography is critical to define vascular anatomy and to prevent significant blood loss and damage to surrounding structures during surgery. This case was presented because TCC of a pelvic kidney is a rare occurrence and the use of robot-assisted nephroureterectomy for treatment of this disease is novel.

Reduced Mortality Associated with Acute Kidney Injury Requiring Dialysis in the United States

BACKGROUND

Dialysis-requiring acute kidney injury (AKI-D) is a documented complication of hospitalization and procedures. Temporal incidence of AKI-D and related hospital mortality in the US population has not been recently characterized. We describe the epidemiology of AKI-D as well as associated in-hospital mortality in the US.

METHODS

Retrospective cohort of a national discharge data (n = 86,949,550) from the Healthcare Cost and Utilization Project's National Inpatient Sample, 2001-2011 of patients' hospitalization with AKI-D. Primary outcomes were AKI-D and in-hospital mortality. We determined the annual incidence rate of AKI-D in the US from 2001 to 2011. We estimated ORs for AKI-D and in-hospital mortality for each successive year compared to 2001 using multiple logistic regression models, adjusted for patient and hospital characteristics, and stratified the analyses by sex and age. We also calculated population-attributable risk of in-hospital mortality associated with AKI-D.

RESULTS

The adjusted odds of AKI-D increased by a factor of 1.03 (95% CI 1.02-1.04) each year. The number of AKI-D-related (19,886-34,195) in-hospital deaths increased almost 2-fold, although in-hospital mortality associated with AKI-D (28.0-19.7%) declined significantly from 2001 to 2011. Over the same period, the adjusted odds of mortality for AKI-D patients were 0.60 (95% CI 0.56-0.67). Population-attributable risk of mortality associated with AKI-D increased (2.1-4.2%) over the study period.

CONCLUSIONS

The incidence rate of AKI-D has increased considerably in the US since 2001. However, in-hospital mortality associated with AKI-D hospital admissions has decreased significantly.

Incidence and In-Hospital Mortality of Acute Kidney Injury (AKI) and Dialysis-Requiring AKI (AKI-D) After Cardiac Catheterization in the National Inpatient Sample

Background

Acute kidney injury (AKI) and dialysis‐requiring AKI (AKI‐D) are common, serious complications of cardiac procedures.

Methods and Results

We evaluated 3 633 762 (17 765 214 weighted population) cardiac catheterization or percutaneous coronary intervention (PCI) hospital discharges from the nationally representative National Inpatient Sample to determine annual population incidence rates for AKI and AKI‐D in the United States from 2001 to 2011. Odds ratios for both conditions and associated in‐hospital mortality were calculated for each year in the study period using multiple logistic regression. The number of cardiac catheterization or PCI cases resulting in AKI rose almost 3‐fold from 2001 to 2011. The adjusted odds of AKI and AKI‐D per year among cardiac catheterization and PCI patients were 1.11 (95% CI: 1.10–1.12) and 1.01 (95% CI: 0.99–1.02), respectively. Most importantly, in‐hospital mortality significantly decreased from 2001 to 2011 for AKI (19.6–9.2%) and AKI‐D (28.3–19.9%), whereas odds of associated in‐hospital mortality were 0.50 (95% CI: 0.45–0.56) and 0.70 (95% CI: 0.55–0.93) in 2011 versus 2001, respectively. The population‐attributable risk of mortality for AKI and AKI‐D was 25.8% and 3.8% in 2001 and 41.1% and 6.5% in 2011, respectively. Males and females had similar patterns of AKI increase, although males outpaced females.

Conclusions

The Incidence of AKI among cardiac catheterization and PCI patients has increased sharply in the United States, and this should be addressed by implementing prevention strategies. However, mortality has significantly declined, suggesting that efforts to manage AKI and AKI‐D after cardiac catheterization and PCI have reduced mortality.

Prostate cancer screening practices and diagnoses in patients age 50 and older, Southeastern Michigan, pre/post 2012

INTRODUCTION

Studies investigating the regional impact of the 2012 U.S. Preventive Services Task Force (USPSTF) recommendation against the use of prostate specific antigen (PSA) screening for prostate cancer have been limited.

METHODS

A retrospective cohort study was conducted on men age 50years and older in Southeastern Michigan pre (n=3647) and post (n=3618) USPSTF recommendation. PSA screening, transrectal ultrasound, and prostate biopsy rates were evaluated pre/post using a generalized piecewise linear model with a Poisson distribution, and log link. A knot was placed at year 2011 to estimate pre/post slope coefficients. Generalized estimating equations were used to estimate the marginal probability of a prostate diagnosis as a logistic function of pre and post-period, and comorbidities.

RESULTS

PSA utilization significantly increased (β=0.28; 95% CI: 0.25, 0.31) during the pre-period, but significantly decreased in the post-period (β=-0.29; 95% CI: -0.34, -0.25). Prostate biopsies decreased pre (β=-0.16; 95% CI: -0.25, -0.08) and did not change post (β=0.01; 95% CI: -0.09, 0.12). Transrectal ultrasounds were stable pre (β=0.16; 95% CI: -0.03, 0.35) and significantly decreased post (β=-0.27; 95% CI: -0.50, -0.04). Patients in the post-period had a decreased probability of having a diagnosis of prostate cancer (OR: 0.81; 95% CI: 0.74-0.89) compared to the pre-period.

CONCLUSION

Our study demonstrates how PSA tests are still being frequently used in Southeastern Michigan. Further research is needed to better understand regional variation in prostate cancer screening practices in the U.S.

Prevalence and Associated Cost and Utilization of Multiple Chronic Conditions in the Outpatient Setting among Adult Members of an Employer-Based Health Plan

Patients with multiple chronic conditions (MCCs) are a significant concern for the US health care system. MCC patients represent an increasing proportion of the US population and are associated with increased health care cost and utilization, and poor quality of care. Research that has been conducted on MCC patients to date has been at the national level using large data sets, such as Medicare and Medicaid claims and the National Inpatient Sample. These studies have produced research evidence that may be of little utility to individual employer-based health plans given the inherent differences in the patient populations they serve. This study analyzed evaluation and management claims for patients ages 18 years and older (n=632,477) from the Beaumont Employee Health Plan (BEHP), a regional health insurance provider serving Beaumont Health System employees and their families across Southeastern Michigan. The study found that individuals with MCCs are associated with increased cost and visits, and decreased time between appointments in the outpatient setting. Despite decreasing prevalence of MCCs over the study period, substantial increases in cost and visits, and a decrease in time between appointments was observed for MCC patients. Asthma and chronic back pain were uniquely identified as additional primary targets for disease management programs for employer-based health plans. These findings speak to the value of studying MCCs at the employer-based health plan level, where population-specific MCCs can be identified for meaningful intervention and management. Significant opportunity exists for employer-based health plans to study, prevent, and manage MCCs among adult patients.

Multiple chronic conditions among outpatient pediatric patients, southeastern Michigan, 2008-2013

Studies investigating the prevalence of multiple chronic conditions (MCCs) and their associated health care cost and use among pediatric populations have been limited. Among 14,404 pediatric patients receiving outpatient care in southeastern Michigan from 2008 through 2013, 82.1% had 0 chronic conditions, 16.2% had 1 chronic condition, and 1.6% had 2 or more chronic conditions. Greater numbers of chronic conditions significantly predicted outpatient cost (β = 581.7, P < .001), visit frequency (β = 9.1, P < .001), and days between appointments (β = −33.9, P < .001). Further study of MCCs among pediatric patients is needed given their increasing prevalence and their associated health care cost and use.

Sex disparities in pre-hospital and hospital treatment of ST-segment elevation myocardial infarction

OBJECTIVE

To determine whether sex disparities exist in pre-hospital and hospital time to treatment in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Evidence suggests that women experience poorer quality of care for STEMI.

METHODS

A retrospective cohort study was conducted on 177 consecutive patients with STEMI who received primary percutaneous coronary intervention at a rural, tertiary medical center between January 2006 and October 2009. A subgroup analysis was conducted to evaluate time to treatment during a period of no-focused process improvement compared with a time period of focused, non–sex-specific process improvement; the post period included implementation of the STEMI process upgrade (STEP-UP) quality-improvement (QI) program.

RESULTS

Median first-emergency-medical-services-contact-to-balloon (E2B) angioplasty time was significantly longer for women compared with men. A Cox proportional hazards model revealed that men had a significantly shorter E2B time than women. After adjustment for differences between sex groups at presentation, the effect of sex on E2B was no longer statistically significant. A similar effect was observed in door-to-balloon (D2B) angioplasty time. The subgroup analysis revealed that from baseline, both men and women experienced improvement in E2B time after implementation of the STEP-UP QI program. Men and women also experienced improvement in D2B time after implementation of the STEP-UP QI program.

CONCLUSIONS

Women with STEMI experienced significantly longer E2B and D2B times compared with men with STEMI, although these differences did not persist after adjustment for differences between sex groups at presentation. In addition to standard STEMI-care QI practices, sex-specific processes and interventions at the systems level may be needed to improve time to treatment for women with STEMI.

Evaluating the communication of environmental permitting decisions in diverse communities

Environmental communication plays a critical role in addressing the public's growing awareness and apprehension about environmental health risks. Although opportunities for public participation in environmental health assessments have greatly increased, environmental communication among key stakeholders is an evolving process. The authors evaluated the communication that occurred among a state environmental agency, six Title V operating facilities, and the public concerning environmental permitting decisions perceived to impact environmental and human health. The authors identify environmental concerns of diverse communities, analyze communication among key stakeholders regarding environmental permitting decisions, and propose recommendations for practitioners to improve environmental communication strategies among these key stakeholders in either urban or rural communities.